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Buder K, Opherk K, Mazzi S, Rohner K, Weitz M. Non-surgical management in children with non-refluxing primary megaureter: a systematic review and meta-analysis. Pediatr Nephrol 2023; 38:3549-3558. [PMID: 36995462 PMCID: PMC10514100 DOI: 10.1007/s00467-023-05938-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/02/2023] [Accepted: 03/03/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Children with non-refluxing primary megaureter are mostly managed by a watchful approach with close follow-up and serial imaging. OBJECTIVES This systematic review and meta-analysis aimed to determine whether there is sufficient evidence to support the current non-surgical management strategy in these patients. DATA SOURCES A comprehensive search including electronic literature databases, clinical trial registries, and conference proceedings was performed. DATA SYNTHESIS METHODS Outcomes were estimated as pooled prevalence. If meta-analytical calculations were not appropriate, outcomes were provided in a descriptive manner. RESULTS Data from 8 studies (290 patients/354 renal units) were included. For the primary outcome, differential renal function estimated by functional imaging, meta-analysis was impossible due to reported data not being precise. Pooled prevalence for secondary surgery was 13% (95% confidence interval: 8-19%) and for resolution 61% (95% confidence interval: 42-78%). The risk of bias was moderate or high in most studies. LIMITATIONS This analysis was limited by the low number of eligible studies with few participants and high clinical heterogeneity, and the poor quality of the available data. CONCLUSIONS The low pooled prevalence of secondary surgical intervention and high pooled prevalence of resolution may support the current non-surgical management in children with non-refluxing primary megaureter. However, these results should be interpreted cautiously due to the limited available body of evidence. Future studies should overcome existing limitations of imaging methods by using standardized, comparable criteria and report outcome parameters in a quantitative manner. This would allow more sufficient data synthesis to provide evidence-based recommendations for clinical decision-making and counseling. SYSTEMATIC REVIEW REGISTRATION The protocol was registered on PROSPERO under CRD42019134502.
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Affiliation(s)
- Kathrin Buder
- Department of General Pediatrics and Hematology/Oncology, University Hospital Tübingen, University Children's Hospital, Hoppe-Seyler-Str. 1, D - 72076, Tübingen, Germany.
| | - Kathrin Opherk
- Department of General Pediatrics and Hematology/Oncology, University Hospital Tübingen, University Children's Hospital, Hoppe-Seyler-Str. 1, D - 72076, Tübingen, Germany
| | - Sara Mazzi
- Pediatric Nephrology Department, University Children's Hospital Zurich, Steinwiesstr. 75, CH - 8032, Zurich, Switzerland
| | - Katharina Rohner
- Pediatric Nephrology Department, University Children's Hospital Zurich, Steinwiesstr. 75, CH - 8032, Zurich, Switzerland
| | - Marcus Weitz
- Department of General Pediatrics and Hematology/Oncology, University Hospital Tübingen, University Children's Hospital, Hoppe-Seyler-Str. 1, D - 72076, Tübingen, Germany
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Hodhod A, Fermin-Risso C, Farhad M, Cook AJ, Aburezq J, Eid H, Weber BA. Can we improve the usefulness of the diuretic renogram in the diagnosis of ureteropelvic junction obstruction (UPJO) in children? Introduction of mercaptoacetyltriglycine-suspected obstruction scoring system (MAG-SOS). J Pediatr Urol 2023; 19:311.e1-311.e8. [PMID: 36922332 DOI: 10.1016/j.jpurol.2023.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 02/22/2023] [Accepted: 02/25/2023] [Indexed: 03/06/2023]
Abstract
INTRODUCTION Mercaptoacetyltriglycine (MAG-3) renogram is one of the gold standard diagnostic tools of ureteropelvic junction obstruction (UPJO); however, there is no widely agreed indications of pyeloplasty based on MAG-3 findings. In this study, we introduce a renogram scoring system that can help improve the prognostic value of MAG-3 renogram and in the decision making of pyeloplasty. PATIENTS AND METHODS We retrospectively reviewed consecutive pyeloplasties for antenatal hydronephrosis from 2010 to 2020. A control group was included of non-operatively managed SFU grade 3 and 4. The initial renal ultrasound and preoperative MAG-3 Lasix renogram were reviewed for differential renal function (DRF), type of renogram curve and tracer washout half-time (T1/2). A ROC curve was used to evaluate the cut-off points that can be associated with obstruction. A multivariate linear regression model was used to assess the best renogram parameter that can predict surgical intervention. RESULTS We included 188 patients with 209 renal units. The median age for pyeloplasty was 5.4 months. The mercaptoacetyltriglycine-Suspected Obstruction Scoring System (MAG-SOS) was associated with pyeloplasty (AUC = 0.97, P < 0.001) (Figure A). A score of 5 is 100% specific for obstruction. 78% of units required surgical intervention had a MAG-SOS score of≥5 while all units of the control group had a range of score 0-4. Using the multivariate analysis, the MAG-SOS system showed to the only independent predictor for pyeloplasty (HR = 0.03, p < 0.001). DISCUSSION This study has some limitations. Firstly, the retrospective nature of the cohort; however, all patients were reviewed by one investigator who was blinded to the line of management. This is a single institutional study; therefor, this MAG-SOS should be evaluated by other centers to ensure its efficiency. Lastly, the pyeloplasty decision was taken by 3 different urologists; nevertheless, all of them adopt the same indications which are similar to those of the Society for Pediatric Urology and the Canadian Urological Association guidelines. CONCLUSION The MAG-SOS system showed to be a useful tool that can predict pyeloplasty. A score of 5 has 100% specificity for patients having a pyeloplasty performed. Prospective studies are required to confirm the usefulness of this novel tool.
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Affiliation(s)
- Amr Hodhod
- Pediatric Urology, Alberta Children's Hospital, Calgary, AB, Canada.
| | | | - Mutaz Farhad
- Pediatric Urology, Alberta Children's Hospital, Calgary, AB, Canada
| | - Anthony J Cook
- Pediatric Urology, Alberta Children's Hospital, Calgary, AB, Canada
| | - Jarrah Aburezq
- Pediatric Urology, Alberta Children's Hospital, Calgary, AB, Canada
| | - Hadeel Eid
- Pediatric Radiology, Montreal Children's Hospital, Montreal, QC, Canada
| | - Bryce A Weber
- Pediatric Urology, Alberta Children's Hospital, Calgary, AB, Canada
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Chirurgische Intervention bei der kindlichen Ureterabgangsstenose. Monatsschr Kinderheilkd 2022. [DOI: 10.1007/s00112-022-01664-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Bar-Sever Z, Shammas A, Gheisari F, Vali R. Pediatric Nephro-Urology: Overview and Updates in Diuretic Renal Scans and Renal Cortical Scintigraphy. Semin Nucl Med 2022; 52:419-431. [PMID: 35031115 DOI: 10.1053/j.semnuclmed.2021.12.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/06/2021] [Indexed: 11/11/2022]
Abstract
Nuclear medicine offers several diagnostic scans for the evaluation of congenital and acquired conditions of the kidneys and urinary track in children. Tc-99m-MAG 3 diuretic renal scans are most commonly used in the evaluation and follow up of urinary track dilatations. They provide functional information on the differential renal function and on drainage quality which is allows distinction between obstructed and non-obstructed kidneys and the need for surgical correction vs conservative management in kidneys with impaired drainage. Standardized imaging and processing protocols are essential for correct interpretation and for meaningful comparisons between follow up scans. Different approaches and conceptions led to some contradicting recommendations between SNMMI and EANM guidelines on diuretic renography in children which caused confusion and to the emergence of self-made institutional protocols. In Late 2018 the two societies published joint procedural guidelines on diuretic renography in infants and children which hopefully will end the confusion. Tc-99m DMSA scans provide important information about the function of the renal cortex allowing detection of acute pyelonephritis, renal scars dysplasia and ectopy as well as accurate determination of the differential renal function. They are commonly used in the evaluation of children with urinary tract infections and affect clinical management. A standardized imaging and processing protocol improves the diagnostic accuracy of these studies. SPECT or pinhole images should be a routine part of the imaging protocol. This is one of the recommendations in the new EANM and SNMMI procedural guidelines for renal cortical scintigraphy in children available online on the SNMMI website and is under publication. This article provides an overview on the clinical role of diuretic renography and cortical scintigraphy in children and describes the imaging protocols focusing on the new recommendations in the procedural guidelines.
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Affiliation(s)
- Zvi Bar-Sever
- Department of Nuclear Medicine, Schneider Children's Medical Center, Petach Tikva, Tel-Aviv University, Israel.
| | - Amer Shammas
- Department of Nuclear Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario Canada
| | - Farshid Gheisari
- Department of Nuclear Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario Canada
| | - Reza Vali
- Department of Nuclear Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario Canada
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Hodhod A, Turpin S, Petrella F, Jednak R, El-Sherbiny M, Capolicchio JP. Validation of modified diuretic drainage times criteria in congenital hydronephrosis. J Pediatr Urol 2021; 17:832.e1-832.e8. [PMID: 34521599 DOI: 10.1016/j.jpurol.2021.08.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 06/24/2021] [Accepted: 08/12/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION AND OBJECTIVE The value of diuretic renography drainage times in congenital hydronephrosis (AHN) decision making is controversial. Recently, a group suggested a modification to the classically described diuretic drainage time cut-off values. They found that a drainage half-time (T1/2) < 5 min was normal whereas a T1/2 exceeding 75 min predicted pyeloplasty. In addition, they reported on the benefit of a delayed drainage image obtained with gravity assistance. We sought to evaluate the ability of these modified T1/2 criteria to predict pyeloplasty, alone or in combination with a delayed drainage image referred to as Global Washout (GWO). METHODS We retrospectively reviewed 113 patients, including consecutive pyeloplasties for AHN from 2004 to 2018. Patients who underwent pyeloplasty due to low differential renal function (DRF) < 30% or infection were excluded. The control group comprised high grade AHN managed non-operatively. The initial renal ultrasound and MAG 3 Lasix renogram were reviewed for grade, differential renal function (DRF), T1/2 and GWO. A ROC curve was used to evaluate the T1/2 and GWO cut-off points that can predict pyeloplasty, using a p-value of less than 0.05. RESULTS The pyeloplasty group consisted of 62 patients and the control group consisted of 51 patients. Two patients (3%) in the pyeloplasty group had a T1/2 < 5 min whereas 21 (34%) had T 1/2 > 75 min (p < 0.001). In the control group, 25 patients (49%) had T 1/2 < 5 min and none had T1/2 >75 min (P < 0.001). The ROC curve for T1/2 < 5 min demonstrated 94% sensitivity and 51% specificity whereas a T1/2 >75 min demonstrated 100% specificity and 34% sensitivity. Analysis of the GWO using a ROC curve revealed that a cut-off of 50% GWO has 100% specificity and 52% sensitivity for pyeloplasty. Overall, a T1/2 > 75 min or GWO <50% predicted 53% of pyeloplasties (Fig A) and was absent in all conservatively managed cases. DISCUSSION The limitations of the present study include its retrospective nature. Secondly, the lack of a gold standard diagnostic test for uretero-pelvic junction obstruction hampers objective quantification of diagnostic test utility performance. CONCLUSIONS We confirm the utility of the modified diuretic half-time criteria and delayed gravity assisted imaging. A T1/2 > 75 min or GWO <50% are indicators of severity whereas a T1/2 of <5 min or GWO >90% is reassuring. Gravity assisted delayed imaging can be especially helpful in cases with indeterminate T 1/2 times and should be included in the standard assessment of hydronephrotic kidneys. These parameters can be used to tailor the frequency and invasiveness of imaging within observation protocols.
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Affiliation(s)
- Amr Hodhod
- Divisions of Urology, Departments of Pediatric Surgery and Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada; Division of Pediatric Urology, Department of Pediatric Surgery, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Sophie Turpin
- Divisions of Nuclear Medicine, Departments of Radiology, Montreal Children's Hospital and CHU Sainte-Justine, McGill University and Université de Montreal, Montreal, Quebec, Canada
| | - Francis Petrella
- Divisions of Urology, Departments of Pediatric Surgery and Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Roman Jednak
- Divisions of Urology, Departments of Pediatric Surgery and Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - Mohamed El-Sherbiny
- Divisions of Urology, Departments of Pediatric Surgery and Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada
| | - John-Paul Capolicchio
- Divisions of Urology, Departments of Pediatric Surgery and Surgery, Montreal Children's Hospital, McGill University, Montreal, Quebec, Canada.
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Younsi N. Diagnostisches Management des primären Megaureters. Urologe A 2020; 59:261-265. [DOI: 10.1007/s00120-020-01119-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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7
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Konnatale Dilatationen der oberen Harnwege. Urologe A 2018; 57:969-986. [DOI: 10.1007/s00120-018-0747-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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8
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Beetz R. Konnatale Dilatationen der oberen Harnwege. Monatsschr Kinderheilkd 2018. [DOI: 10.1007/s00112-018-0500-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Capolicchio JP, Braga LH, Szymanski KM. Canadian Urological Association/Pediatric Urologists of Canada guideline on the investigation and management of antenatally detected hydronephrosis. Can Urol Assoc J 2017; 12:85-92. [PMID: 29319488 DOI: 10.5489/cuaj.5094] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
| | - Luis H Braga
- McMaster Children's Hospital, McMaster University, Hamilton, ON, Canada
| | - Konrad M Szymanski
- Riley Hospital for Children at Indiana University Health, Indianapolis, IN, United States
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Ballouhey Q, Lescure V, Larradet M, El-Badaoui A, Grimaudo Benaïssa A, Guigonis V, Monteil J, Verbeke S, Fourcade L. [Pitfalls for renogram interpretation in pediatric urology]. Arch Pediatr 2015; 23:66-70. [PMID: 26481045 DOI: 10.1016/j.arcped.2015.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 05/11/2015] [Accepted: 09/20/2015] [Indexed: 11/25/2022]
Abstract
Renograms are currently used for functional assessment by pediatric urologists. The aim of the present work was to focus on the potential pitfalls concerning renography. Potential confounding factors are described in reference to concrete cases. The main types of pitfalls concern venous or urinary catheters and background area definition. Protocols and renogram interpretation are critiqued in a bibliographic review. We propose a technical update and original data on the potential pitfalls in renography interpretation. Multidisciplinary discussion between nuclear medicine, pediatrics and pediatric surgery departments is required before drawing conclusions.
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Affiliation(s)
- Q Ballouhey
- Service de chirurgie pédiatrique, hôpital des Enfants, 8, avenue Dominique-Larrey, 87042 Limoges cedex, France.
| | - V Lescure
- Service de chirurgie pédiatrique, hôpital des Enfants, 8, avenue Dominique-Larrey, 87042 Limoges cedex, France
| | - M Larradet
- Service de médecine nucléaire, hôpital Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
| | - A El-Badaoui
- Service de médecine nucléaire, hôpital Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
| | - A Grimaudo Benaïssa
- Service de chirurgie pédiatrique, hôpital des Enfants, 8, avenue Dominique-Larrey, 87042 Limoges cedex, France
| | - V Guigonis
- Service de pédiatrie, hôpital des Enfants, 8, avenue Dominique-Larrey, 87042 Limoges cedex, France
| | - J Monteil
- Service de médecine nucléaire, hôpital Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
| | - S Verbeke
- Service de médecine nucléaire, hôpital Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges cedex, France
| | - L Fourcade
- Service de chirurgie pédiatrique, hôpital des Enfants, 8, avenue Dominique-Larrey, 87042 Limoges cedex, France
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